Critical Care - What is The Latest?

Knowledge Pathway Alert: Critical Illness

The Critical Illness KP is updated! The update includes these practice questions:

• What are the energy and protein requirements of critically ill adults?
• What are the energy and protein requirements of critically ill adults with higher weights (BMI ≥30 kg/m2)?
• What nutrition screening and assessment tools can be used to identify nutritional risk and to assess malnutrition in critically ill adults?
• Does immunonutrient supplementation improve patient outcomes in critically ill adults?
• Does the use of enteral versus parenteral nutrition or enteral nutrition combined with parenteral nutrition result in improved outcomes in critically ill adults?
• What strategies are effective to optimize delivery of enteral nutrition and minimize risks in critically ill adults (e.g. feeding protocols, motility agents, positioning)?
• Does early enteral nutrition (initiating feeding within 48 hours of admission to ICU) versus delayed enteral nutrition (initiated within 48 to 96 hours of admission) result in improved outcomes in critically ill adults?
• Does continuous administration of enteral nutrition compared with intermittent or bolus feeding result in better outcomes in critically ill adults?
• Does enteral feeding into the small intestine (post-pyloric) compared to gastric feeding result in improved outcomes in critically ill adults?
• Is the practice of measuring gastric residual volume (GRV) in mechanically ventilated critically ill adults who are tube fed into the stomach reliable for predicting tolerance, regurgitation and aspiration? What is considered an acceptable GRV?
• What nutrition monitoring (e.g. overfeeding, underfeeding, refeeding syndrome) is recommended for critically ill adults receiving nutrition support?

For a concise summary of these practice questions, see the Critical Illness Summary of Recommendations and Evidence.

Looking for related content? See the following knowledge pathways:

• Nutrition Support - Enteral and Parenteral
• Malnutrition
• Wound Care and Pressure Injuries
• Nutrition Assessment - Adult
• Traumatic Brain Injury

Bowel Obstruction and a Low Fibre Diet – What is the Latest?

There is no direct evidence supporting or refuting the use of a low fibre diet to prevent bowel obstruction in individuals with inflammatory bowel disease (IBD). However, it is common practice to reduce insoluble fibre intake in individuals with IBD and intestinal stenosis, stricture or asymptomatic bowel obstruction and this practice is supported by knowledge of physiology. 

There is no evidence suggesting that individuals with IBD (Crohn’s disease or ulcerative colitis) who do not have bowel obstruction should reduce their dietary fibre to reduce the risk of bowel obstruction, regardless of whether or not they are experiencing a disease flare. However, fibre is often perceived to worsen symptoms, and individuals with IBD may wish to avoid it during a flare.

Evidence examining dietary fibre manipulation in individuals with other risk factors for bowel obstruction is lacking. 

A 2022 narrative review recommended that fibre can be restricted in individuals with IBD and intestinal stenosis or stricture, but there is no reason to reduce dietary fibre in individuals with IBD who do not have bowel obstruction. 

The 2020 ESPEN practical guidelines for the management of IBD recommend reducing insoluble fibre in the case of asymptomatic bowel obstruction. This is considered a good practice point based on indirect evidence. 

The 2023 British Dietetic Association (BDA) guidelines for the dietary management of IBD recommend that individuals with stable IBD do not need to restrict their fibre intake to prevent bowel obstruction whether or not they are experiencing a disease flare, but individuals with stricturing IBD may benefit from limiting insoluble fibre and consuming soluble fibre and water together. The authors noted that fibre is often perceived to worsen symptoms, and individuals with IBD may wish to avoid it during a flare.
Grade of Evidence C 

There is a lack of clinical trials to support limiting dietary fibre in individuals with other risk factors for bowel obstruction (e.g. previous bowel surgery, adhesiolysis).
Grade of Evidence D

The Remarks 

The terms "low residue" and "low fibre" diet are often used interchangeably. It has been suggested that the term low residue diet could be redefined as a low fibre diet. Quantitatively, this could be defined as providing no more than 10 g fibre/day, although the definition is not standardized.

It is not possible from an ethical point of view to conduct clinical trials in individuals where dietary fibre could cause a mechanical obstruction, which may explain the lack of research in this area.

See Additional Content: 

What is the efficacy of the autoimmune protocol diet for improving quality of life and reducing the symptoms experienced by adults with an autoimmune disease?
What are the optimal dietary strategies for managing constipation in adults receiving cancer treatment?
Food Sources of Fibre.

To see the full practice question, including the Evidence Statements, Comments and References, click here.

Looking for related Knowledge Pathways?
Cancer - Colorectal
Gastrointestinal System - Inflammatory Bowel Disease
Gastrointestinal System - Ostomy
Gastrointestinal System - Cleansing

Strategies that May Improve Food and Nutrient Intake of Adults in Hospital

What strategies can improve intake or nutritional outcomes of adults in hospital (e.g. food service system modifications, protected mealtimes, mealtime assistance, multidisciplinary approaches)?

Food service system changes, menu modifications, attractive meal presentation, providing feeding assistance and multidisciplinary approaches at the individual, ward and/or organizational level may be associated with an increase in food and nutrient intake and meal experience for adults in hospital. The effect of protected mealtimes on nutritional intake is unclear due to inconsistent effects. 

Few studies have examined the impact of these interventions on nutritional, functional or clinical outcomes, preventing conclusions from being drawn.  

In the included studies:

• Food service system modifications focused on bedside meal ordering systems using technology or verbal prompts, room service style and trolley delivery systems.
• Menu modifications and composition interventions included energy- and protein-enriched meals or snacks; adding condiments to the menu; high protein, high energy snacks; and patient-centred recipe modifications.
• Enhanced meal presentation included garnishes and attractive presentation of hospital meals.
• Protected mealtimes, mealtime environment and mealtime assistance included the introduction of mealtime volunteers or trained food caregivers to provide assistance with eating, time and positioning during mealtime or mid-meals.
• Multidisciplinary approaches referred to active teamwork used to develop and deliver optimal care plans for inpatients that occurred at the individual, ward and/or organizational level. Examples included staff training and interventions related to food and nutrition monitoring. 

See Additional Content: Should adults with malnutrition or at risk of malnutrition be recommended nutrition intervention in hospital?

Click here to see the full practice question, including the Evidence Summary, Evidence Statements, Comments and References.

Blenderized Tube Feeding Versus Commercial Enteral Formula – Is There a Difference?

In the included studies, adults who were identified as malnourished or medically complex at risk of malnutrition included individuals with head and neck cancer, gastrointestinal cancer, those who were immunocompromised, with a malabsorptive disorder or disease or presenting with a critical illness.  

Click here to see the full practice question, including the Evidence Summary, Evidence Statements, Comments and References.

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